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AS BUILT SANITARY SYSTEM REPORT--__
~ T' N, R W
OWNEFc TOWNSHIP J•{u m v,; o
P.O. ADDRESS ST.-CROIX COUNTY, WISCO r
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100FEET OF SYSTEM
1oG d -
ZVI
n
I SEPTIC-'TANK(S) ~ 00 MFGR. CONCRETE STEEL
f NO. of rings on cover Depth DRY WELL
TRENCHES No. of width I-ength area
BED no. o- lines width ,,y length area
dept to top of pipe
AGGREGATE f2
PERK RATE AREA REQUIRED AREA AS BUILT
DISCLAIMER: The inspection of this system by St, Croix County does not imply
complete compliance with State Administrative Codes. There are other areas
that it is not possible to inspect at this point of construction. St. Croix
County assumes no liability for system operation. Hcwever, if failure is
noted the County will make every effort to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
INSPECTOR
DATED PLUMBER ON JOB .116
LICENSE fir` t P 40 ? 7
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitaty Permit-- t~
State Septic-
NAME- Township St. Croix County
Location 0% o i, 314, Section f 'T_N, R W
SEPTIC TANK
Size 4)-,!~>o _gatton6. Numbet o6 Compattment6 /
Distance Ftom: weU it. 12% oA gteateA stope it
Building 11 it. Wettands ~ .
HighwateA it.
DISPOSAL SYSTEM
Di.stance Ftom: G1eU it. . 1 2 % of gteaxet 6Zope it.
Building it. WetZands ~o- Ft.
HighwateA it.
FIELD DIMENSIONS: /
iWidth o6 trench 3 it. Depth o6 Ao ck b etow tiZe tin.
Length o6 each .tine ~~g it. Depth o6 tock over tiZe in.
Numbet ob Zine/s Depth o6 tiZe below gtade _ s{-. in.
TotaZ .length of tines it. Stope o6 tAench -in pet 100 it.
f
Di, stance between Zines it. Depth to b edto ck -.1 it.
Tatat abs otbtion atea b 2 Depth to gtoundwa et ~ .
2
RequiAed area it
PIT DIMENSIONS:
Numbet a4 pits Gtavet around pits yes no
Outside diameter 1 74 b Depth below inZet it.
Totat ab6otbtion atja it 2
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Area tequited bt2 rn
INSPECTED BY TITLE
APPROVED _ r f r , DATE 19 7
REJECTED DATE 197.
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PLB67 State and County State Permit #
Permit Application County Permit'
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
Homes & Domes Inc (Spec. House) Hammond, Wisconsin
B. LOCATION: NW_'/4 NE '/4, Section 18, T_29_ N, R_ ~ (or)(W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# _ Village Hammond
Township
a- TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family X Duplex No. of Bedrooms 3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES X NO Food Waste Grinder YES X NO # of Bathrooms
Automatic Washer X YES NO Other (specify)
E. SEPTIC TANK CAPACITY 1000 Total gallons No. of tanks 1
`Holding tank capacity None Total gallons No. of tanks
PI 'e w Installation Z Addition Replacement Prefab Concrete Z
'Poured in Place Steel Other (specify)
EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2.5 2) 2 3) _ 5 Total Absorb Area !;8 sq. ft.
New Z Addition Replacement *Fill System _
Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length *2~16-_Width 18 Depth 40 Tile Depth 364 No. of Lines 3
Seepage Pit: Inside diameter Liquid Depth Tile Size 4"
Percent slope of land Distance from critical slope
1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME Stephen L. Baby C.S.T. # 1406 and other information
obtained from Homes:. Sc Domes 1110 (owner/builder).
Plumber's Signature MP/MPRSW# 5181. Phone # 698 -2407
Plumber's Address . Wood il s, l WisC
PLAN VIEW: Provid- sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space Below FOR DEPARTMENT USE ONLYi
Date of Application Fees Paid: State County s. Date
Permit Issued/R„gjwA&d- (date) _Issuing Agent Name 6
4,4
Inspection Yes__LNo Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1 /76
EH 115
I - WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: Section 16- Ta N, R 174 (or) W, Township or Municipality Hafmioad, Wise
Lot No. T , Block No. County
Jack Foster Subdivision Name
Owner's Name:
Mailing Address: Hammond, Wisconsin
TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 5 May 77 PERCOLATION TESTS 7 May 77
SOI L MAP SHEET __-__2' - F "j?__ SOI L TYPE Etter Loams (deep)
PERCOLATION TESTS
I TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
"JUM- INCHES THICKNESS IACTERN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P 1 48 TOP, soil 10", Clay 124, Sand 26" $ yeas 10 Min 4" 4" 42.5
P 2 4$ op soil 10", Clay 120, Sand 26 $ yea 10 Min 5"'Ll 5" 2
i
P-
3 4$ op 3mti1 100; Clay 120, Sand 26 $ yes 10 Min 2" 2" 2" 5
SOIL BORING TESTS l
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES I
j CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
G _ 1 96." none none Top soil 10" clay 12" sand 74'
i 2 96" none none Top soil 10" clay 12" sand 74"
f~ 3 960 none none Top soil 10" clay 12" sand 74"
4 96" None none Top soil 10" clay 123 sand 74"
p soil 10" c ay sand (4"
(a_5 964 none none TTOO-0
6 960 none none soil 10" clay 120 sand 74" j
PIAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
1, icate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. 6300 sq. £t. Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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I I
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct
to the best of my knowledge and belief.
Name (print) Stephen L Aaby Certification No. 55~1400
Address Woodville,; Wisconsin
i
Name of installer if known
CST Signature,, v z~z/I,-
~COPY A -LOCAL AUTHORITY Cam.